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Letters to the Editor  |   November 2005
Report of Case: Relapse of Condyloma Acuminatum and Mistrust of Physicians in Homeless Patient
Author Affiliations
  • Timothy P. Plackett, OMS III
    Chicago College of Osteopathic Medicine Downers Grove, Illinois Rainbow Clinic Aurora, Illinois
  • Marilyn Scott, MS, APN
    Rainbow Clinic Aurora, Illinois
    Volunteer Director
Article Information
Obstetrics and Gynecology / Urological Disorders
Letters to the Editor   |   November 2005
Report of Case: Relapse of Condyloma Acuminatum and Mistrust of Physicians in Homeless Patient
The Journal of the American Osteopathic Association, November 2005, Vol. 105, 492-493. doi:10.7556/jaoa.2005.105.11.492
The Journal of the American Osteopathic Association, November 2005, Vol. 105, 492-493. doi:10.7556/jaoa.2005.105.11.492
To the Editor:  
In March 2004, a 40-year-old homeless male reported to our clinic complaining of a large, painful mass growing posterior to his scrotum. The patient rated the severity of the pain as an 8 on an ascending scale with 10 as the most severe. He noted that the pain was worse when he sat on cold concrete, and that walking provoked additional pain. His pain while sitting was so unbearable that it interfered with his ability to operate a forklift, resulting in the subsequent loss of his job. 
Upon physical examination, a fungating mass measuring 4 cm by 7 cm, consistent with condyloma acuminatum, was noted posterior and to the left of the scrotum (Figure). The mass was ulcerated and bleeding. The patient stated that the bleeding occurred daily and required that he dispose of his undergarments every 1 to 2 days. 
A focused history of the patient revealed a case of a similar-sized lesion that was noted in 1992 on the posterior right side of the scrotum. The patient was treated for this lesion in 1996 with cryotherapy and carbon dioxide laser ablation. However, the condition was complicated by a subsequent infection of the surgical wound, resulting in the reappearance of a small lesion within a few weeks of surgery. In 1998, there was an unsuccessful attempt to eliminate the lesion with acid treatment. Subsequent to that treatment, the lesion continued to grow. 
Approximately five weeks before the patient arrived at our clinic, the condyloma acuminatum began to ulcerate and tear, leading to a rapid growth of the lesion. According to the patient, the lesion grew by some 50% during that period. 
The patient's past medical history was significant for alcoholism, but the physical examination at the clinic was otherwise within normal limits. The patient was referred to a local hospital for treatment. However, as is the case with many of the homeless patients who are treated at our clinic, follow-up care was not performed because the patient moved and could not be located again. 
Condyloma acuminata are usually cauliflowerlike masses found on the urethra, penis, female genitalia, perianal area, or rectum.1 The lesions are typically limited to a few centimeters in diameter at the time of presentation to physicians. Human papillomavirus type 6 and type 11 are responsible for most cases of condyloma acuminatum,1 which affects slightly more than 1% of the adult population.2 The peak incidence occurs in individuals who are between 20 and 24 years old, with a peak prevalence in individuals 17 to 33 years old.3 The differential diagnoses for such large, bleeding masses include bowenoid papulosis, Buschke-Löwenstein tumor, condyloma latum, and squamous cell carcinoma.1 
Surgical treatment options include cauterization, laser ablation, and surgical excision.4 However, only 36% of patients remain free of condyloma acuminatum three months after surgery.4 Pharmacologic treatment usually involves topical therapy with imiquimod or podophyllin.4,5 Although pharmacologic treatment is effective for 70% of patients, the rate of long-term cure with this treatment modality is only 60%, at best.5 
Figure. Condyloma acuminatum lesion posterior and to the left of patient's scrotum.
Figure. Condyloma acuminatum lesion posterior and to the left of patient's scrotum.
Patients need to be educated about the risk of relapse. The patient in this case was not informed of the low rate of remaining asymptomatic after surgery. When the condyloma acuminatum returned, the patient developed a distrust of physicians—a distrust that contributed to his refusal to seek treatment until the lesion grew quite large. Proper education from his physician might have encouraged the patient to seek treatment sooner, making it unlikely that he would have lost his job. 
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Ghadishah D. Condyloma acuminata [eMedicine.com Web site]. April 29, 2005. Available at: http://www.emedicine.com/EMERG/topic107.htm. Accessed September 23, 2005.
Takahashi S, Shimizu T, Takeyama K, Kunishima Y, Hotta H, Koroku M, et al. Detection of human papillomavirus DNA on the external genitalia of healthy men and male patients with urethritis. Sex Transm Dis. 2003;30:629-633.
Fazel N, Wilczynski S, Lowe L, Su LD. Clinical, histopathologic, and molecular aspects of cutaneous human papillomavirus infections [review]. Dermatol Clin. 1999;17:521-536.
Maw RD. Treatment of anogenital warts [review]. Dermatol Clin. . 1998;16:829-834.
Von Krogh G, Longstaff E. Podophyllin office therapy against condyloma should be abandoned [review]. Sex Transm Infect. . 2001;77:409-412. Available at: http://sti.bmjjournals.com/cgi/content/full/77/6/409. Accessed September 23, 2005.
Figure. Condyloma acuminatum lesion posterior and to the left of patient's scrotum.
Figure. Condyloma acuminatum lesion posterior and to the left of patient's scrotum.